Early this month, Glenn S. Ross, FACP, will drive an hour from his home in Newport News, Va., to take the final exam to recertify in internal medicine. The six-hour test will be the culmination of more than a year of preparation, which for Dr. Ross meant spending Saturdays in medical libraries away from his wife and three small children, and chasing down answers from colleagues in the midst of a 65-hour work week.

While Dr. Ross is confident he'll pass the exam, the process has left him with a sense of frustration, not accomplishment. "I studied conditions that I'll run into maybe once in my entire career," he said. "I cornered subspecialists in the hospital with questions that they couldn't answer. I feel my own specialty has put me through major hoops and hurdles, and I don't feel I'm a better doctor for having done so."

Dr. Ross is one of 8,500 internists who must this year get recertified with the American Board of Internal Medicine (ABIM) or lose their board certificates. Like many of his colleagues, Dr. Ross has found it hard to shoehorn more than 100 hours of preparation into an already hectic life.

As the final exam approaches, however, complaints about recertification's inconvenience and irrelevance are giving way to new anxieties. Some internists fear that they will be among the 10% of test-takers who are expected to fail the final exam on their first try. That could hurt their practices, their careers and possibly their patients, who may find their doctor being temporarily dropped from their health plan. (The next exam for internal medicine is not offered until May 2001.)

Individual internists aren't the only ones facing problems. With some subspecialists deciding not to recertify in internal medicine, some hospitals are already anticipating disruptions in their call coverage and attending schedules.

The College has formed a task force to take members' concerns to the ABIM--and to voice objections of its own. ACP­ASIM officials say that the ABIM's recent revisions to the recertification process seem to stray far from the board's role of evaluation and into the College's domain of education. It is just one more concern that has emerged as internists embark on a new, career-long relationship with the internal medicine board.

An irrelevant process?

Internists have known since 1987 that mandatory recertification would become reality. That's when the ABIM announced that its efforts to persuade internists to voluntarily recertify had failed, leading it to create two tiers of diplomates. Internists who became board certified before 1990 have lifetime certificates, while internists certified during or after 1990 are given 10-year certificates. (ABIM officials say they would have faced too many legal challenges if they tried to revoke older physicians' lifetime certification.)

Since 1995, the recertification process has included both a self-evaluation process (SEP)--with five different sets of 60 questions each--and a pass-fail exam. (Subspecialists recertifying in both a subspecialty and internal medicine must take additional SEP and exam modules.) The board says that it takes on average 15 hours to complete each SEP set--which translates, as one internist put it, to about 60 patients that an internist cannot see.

Time is only one of many beefs that internists have with the recertification process. Some also object to the cost: $825 for internal medicine recertification, $200 more for each subspeciality or added qualification, plus a day away from practice for the exam.

There is also travel time and expense for many physicians. Patrick G. Quinn, FACP, for instance, who will take the final exam this month in gastroenterology, must fly to Phoenix because he said the exam is not offered in his home state of New Mexico.

But the complaint that comes up again and again in conversations with internists is that too much of the recertification process is irrelevant to daily practice. While most internists say that they support the principle of time-limited certification, they are angry at a process they say doesn't enhance their knowledge or skill as physicians.

The complaint that comes up again and again is that too much of the recertification process is irrelevant to daily practice

Like Dr. Ross, Dr. Quinn said he found many of the SEP questions obscure or ambiguous, and he is afraid he'll find more of the same on the exam. The average combined pass rate for internists taking the internal medicine and subspecialty exams for the first time is between 90% and 92%, according to the ABIM. (Board officials emphasize that they expect the overall pass rate to reach 98% as internists who failed on their first try retake the exam.) Yet Dr. Quinn said he has heard anecdotal evidence that the fail rate for first-time takers in gastroenterology is hitting 12%.

"Does that mean that 12% of those gastroenterologists--all of whom completed fellowships, passed the boards once already and have been practicing medicine--are incompetent?" he asked. "Either they shouldn't have made it through the system in the first place, or the exam isn't gauging the right thing."

Those one-in-10 odds are rattling internists who may find their livelihoods put on hold if there is a lapse in certification, said John M. Van Etta, FACP, an internist in Duluth, Minn., and the immediate past president of the Minnesota Medical Association. Because employers, hospitals and HMOs all demand board certification, Dr. Van Etta said, recertification has unwittingly become a tool for economic credentialing.

"When we do these things to one another," he said, speaking of physicians, "it is to the glee of third-party payers and nonphysicians who are already making inroads into our practice and who don't have to recertify."

Subspecialty fallout

While most general internists have to recertify in order to stay on hospital staffs or HMO panels, some subspecialty internists are taking a different view. To save time and money, they may drop their internal medicine certification and renew only their subspecialty certificate.

The ABIM says it is too early to predict how many subspecialists will take that route, but anecdotal evidence suggests that significant numbers may do just that. Gastroenterologist Dr. Quinn, for instance, had planned to recertify in internal medicine to brush up on his skills, but he has changed his mind because of the time commitment. "Paradoxically," he pointed out, "I'll be a Fellow of the College without being board certified in internal medicine." (College officials have said that they will not revoke Fellowship for members who lose their board certification.)

Dr. Quinn will also no longer be part of emergency room call for internal medicine, which is now a part of his job. "The potential legal liability for both me and the hospital is too great if I'm not board certified," he explained.

While institutions around the country are anticipating similar problems, small community hospitals may be hardest hit. At Winchester Medical Center in Winchester, Va., for instance, there is concern that many of the subspecialists who are now part of the emergency room roster for unassigned patients will let their internal medicine certificates lapse. (Winchester's bylaws, like those of most hospitals, require physicians to be board certified.)

According to Jeffrey P. Harris, FACP, the College's Governor for the Virginia Chapter and an internist with Winchester Medical Consultants, having fewer subspecialists taking general call will mean more middle-of-the-night emergency room visits for generalists, who are already in short supply. To solve the dilemma, the hospital for the first time is hiring hospitalists to admit unassigned patients.

In academic medical centers, department chairs have already started looking at their roster of attendings, worried that subspecialists may no longer be certified to attend on general medicine wards. The University of Minnesota School of Medicine, for instance, believes that "a majority" of its subspecialists may let their internal medicine certificates lapse, according to Tanya L. Repka, FACP, Governor for the Minnesota Chapter and assistant professor of hematology, oncology and transplantation. It intends to solve the attending dilemma by considering board-certified subspecialists with lapsed general certificates as "board-eligible" indefinitely.

Some worry that outpatient care may be affected if many subspecialists with lapsed internal medicine certificates decide to no longer attend to patients' non-subspecialty conditions. Without internal medicine certification, subspecialists concerned about liability may need to send patients for more primary care visits--increasing health care costs, analysts say, and disrupting continuity of care.

Changing the process

The ABIM has already begun to revamp the process, and officials predict that it will address some of internists' concerns. "Lapses in certification are not in either the patient's or the diplomate's best interests," said ABIM president Harry R. Kimball, MACP. "That's part of the reason that we're moving to a more continuous process, so that work doesn't all pile up at the end."

This summer, the ABIM announced changes to recertification in the Aug. 1 issue of Annals of Internal Medicine. Under the new process, which the ABIM calls Continuous Professional Development (CPD), physicians must begin recertification efforts in the fourth year of their cycle and complete a self-evaluation module every one to two years. The written exam will not have to be the last component completed; physicians will be able to take the final exam any time after the sixth year of their 10-year cycle, giving those who fail plenty of opportunities to re-take the test.

Under the revamped process, which is now being phased in, the self-evaluation modules are being re-tooled to include patient and peer assessments and practice performance evaluations. Dr. Kimball explained that the changes were designed to more closely tie certification to the national focus on improving quality. Yet critics charge that in staking out such broad territory, the ABIM has moved into areas already covered by other national and local accrediting agencies.

E. Rodney Hornbake III, FACP, a member of the College's Education Committee and senior vice president and chief medical officer of Gentiva Health Services in Melville, N.Y., said that physician performance is already being measured by health plans, Medicare and, in many cases, group practices or independent practice associations. "I think it will add very little value to the delivery system," he said.

In response to the charge that such measures are duplicative for many physicians, the ABIM's Dr. Kimball said that the board is willing to accept data from other sources as long as they measure the same elements. Board officials said they will also allow other organizations to incorporate elements of the SEP modules into their own educational programs to help internists avoid duplication of efforts.

Critics point out what they see as other flaws in the new process. Some wonder why none of the required elements give credit for continuing medical education, as CME seems an ideal indicator of maintaining competence. Others claim that involving patients in recertification may be intrusive. And others express concern about what Dr. Hornbake called "a dramatic paradigm shift" as the ABIM moves from a once-in-a-career encounter to an organization with which internists must now have a lifetime relationship.

"Now we're perpetual students instead of scholars," said Faith T. Fitzgerald, MACP, the College's Governor for the Northern California Chapter and program director for internal medicine at the University of California, Davis. She noted that mandatory recertification involves some sense of loss of autonomy. "We've always been students," she said, "but not in the sense of having weekly quizzes, like we're a remedial group."

The College has expressed concern about the new process. In an Oct. 10 letter, the College said that it supports the concept of recertification but emphasized that the process should be simple, cost-effective and not intrusive or time-consuming.

The College has formed a task force to address members' concerns about recertification. That group will also address a major College concern: that the revamped recertification program blurs the line between evaluation--the ABIM's traditional strength--and education, which has been the role of the College and other societies. The new practice performance and clinical skills modules, for instance, seem to compete with College products like the Medical Knowledge Self-Assessment Program and the Clinical Problem-Solving Cases program. The College's Oct. 10 letter emphasized that ACP­ASIM and the ABIM are two separate and independent organizations, and that a distinction between the roles of the two organizations must be maintained to avoid any conflicts of interest.

"We're delighted to compete with legitimate competitors," said Herbert S. Waxman, FACP, the College's Senior Vice President for Education. "But when an organization that controls the awarding of the certificate gets into the education business, you no longer have a level playing field." Critics say that by certifying physicians who use its educational material, the ABIM may be creating a conflict of interest--one that could undermine the integrity of the recertification process.

At press time, the College's task force was scheduled to meet with the ABIM in late October. For many internists, however, the results of those efforts won't come fast enough. Even small rural hospitals now require physicians to be board certified, according to Mark E. Smith, a vice president with Merritt, Hawkins & Associates, a national physician recruiting firm. He warned that the idea that internists can boycott the ABIM and get certified by another body--like the American Association of Physician Specialists--is not a viable option.

"In many cases, hospitals recognize only the ABIM," Mr. Smith said. "To claim that you're certified—through some other entity—borders on misrepresentation."

Besides, most internists don't want to see the specialty split into different certifying camps. "We don't need an alternative," said Minnesota's Dr. Van Etta. "We need to make this one work right."

Recertification gets redesigned

This summer, the American Board of Internal Medicine (ABIM) revamped its recertification program. The Continuous Professional Development program includes the following four elements, which will be phased in over the next four years:

Knowledge. This module is similar to the present self-evaluation process modules. Physicians will have to complete and pass at least one knowledge set to recertify.

Clinical and communication skills. Internists will use a CD-ROM with audio and video to answer questions that test clinical and communication skills. Physicians are required to pass at least one clinical skills module.

Patient-peer assessment. Each physician will have to enroll 10 peers and 25 patients in an automated ABIM telephone survey assessing that physician's integrity, skill and demeanor. After getting the survey results, which will be confidential, each physician will be required to design a personal self-improvement plan. While there is no pass-fail standard for the module, it will be a mandatory part of recertification.

Practice performance. There will be separate interactive modules with clinical vignettes and questions related to different diseases such as diabetes, asthma and congestive heart failure, as well as selected procedures like colonoscopy and preventive services.

Like the patient-peer assessment module, the practice performance portion does not have a pass-fail standard, but physicians will have to design a self-improvement plan based on feedback from the ABIM. Physicians will have to complete a minimum of two practice performance modules to recertify, and the ABIM plans to randomly audit chart results.

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